Best Practices for Advance Care Planning

Care management provides the best opportunity to offer Advance Care Planning. 

Care management helps deliver personalized, goal-oriented, and team-based care, and offers structure and standards that fit well within Advance Care Planning (ACP). 

According to the American Academy of Family Physicians (AAFP), the most effective ACP completion rates are seen when a patient receives repeated counseling, which care management already provides.

It can help ease time constraints and competing priorities that often prevent ACP discussions. 

Create a standardized process and workflow to define “who” and “when”

When designing an Advance Care Planning service, two critical questions are “who” and “when?” Who are the patients you will focus on, and when should a provider introduce an ACP discussion?

Who and when can go hand-in-hand. While having ACP documents in place, and including a healthcare decision-maker (aka proxy), is helpful for every adult, there are three opportune times when broaching Advance Care Planning is indispensable.

These include:

• During a Medicare beneficiary’s Annual Wellness Visit
• When a patient is transitioning from hospital to home or hospital to another care facility
• When a patient’s risk profile and medical condition has worsened or become more complicated

Care management programs, like Chronic Care Management (CCM) and Transitional Care Management (TCM), also offer pivotal opportunities to launch ACP.

Patients participating in CCM are at higher risk. They should have ACP documents in place since they are, by definition, patients with two or more chronic conditions expected to continue for at least a year or until the patient’s death.

The Centers for Medicare & Medicaid Services (CMS) provides a good example of a patient profile when ACP is needed:  

“A 68-year-old person takes multiple medications for heart failure and diabetes. They see their physician for the E/M of these 2 diseases, and the physician adjusts their medications. While discussing short-term treatment options, the patient also wants to address long-term treatment concerns. 

They talk about a possible heart transplant if the heart failure worsens. They also discuss ACP, including the patient’s desire for care and treatment if they have a health event that adversely affects their decision-making abilities, and the physician helps the patient complete a legal advance directive form from their state attorney general’s office. 

According to CPT reporting instructions, the physician may report the ACP codes, in addition to the E/M visit code describing the active management of heart failure and diabetes, as long as the ACP time doesn’t overlap with active management of those conditions.”

Use one workflow for all ACP activities

Once a provider organization has mapped out the who and when, it’s critical to create a standardized process and workflow. This helps providers manage each patient conversation and touchpoint, as well as capture ACP decisions and documents.

ThoroughCare provides a seamless, evidence-based system for managing each ACP component. This includes:

• Notifying care managers about patients who need ACP 
• Integrated educational resources and prompts to help patients assess care values  and priorities
• Legal ACP documentation for all US states

As Figure 1 shows, having one central and standardized workflow ensures that every patient is guided through a consistent process. It also gives the care team peace of mind: They can focus on the patient and their conversations. They won’t miss an essential component of the Advance Care Planning protocol.  

ThoroughCare creates the foundation of your ACP offering. 

By leveraging evidence-based workflow and education, the platform guides the clinician and patient through a structured yet flexible set of steps.

Design a care team approach 

Care management programs leverage a team-based care model, intending to have every member work at the top of their professional license. This is particularly useful and appropriate for Advance Care Planning. 

It also provides a more efficient and cost-effective way to manage the various aspects of ACP. The team can decide which role is best suited for handling each part.

For example, a physician can guide the patient through the entire ACP process. However, other qualified providers, defined under Medicare Part B, can include nurse practitioners, physician assistants, and clinical nurse specialists.

You can design your approach around which team members are most appropriate, skilled, and suited to certain aspects of ACP. Or, you may decide to rotate roles so that all nurses and CNAs handle the overall process. However, the physician should introduce the topic, or advise on which medical interventions could best fit the patient’s care goals and treatment preferences. 

The beauty of a team-based approach to ACP is that ThoroughCare is already set up to handle collaborative care.

Care team and provider confidence is paramount

Beyond having clear workflows and standards, the confidence of the provider and care team in addressing sensitive subjects, such as Advance Care Planning and medical decision-making, can be a significant barrier.

Research has shown that ACP involving a facilitated conversation with a healthcare professional is more effective than document completion alone. 

For professionals to have a level of comfort and competence around subjects not typically addressed in medical or nursing school, it’s critical to have access to adequate training. 

Leadership support for ACP training provides opportunities for teams to learn about its requirements, as well as training, including:

• Initiating ACP conversations
• Discussing how a patient’s current medical condition merits advance planning
• Providing education on various medical interventions
• Assessing preferences and values
• Assistance with sensitive questions
• Engaging the patient’s family
• Supporting the patient in choosing a medical decision-maker and backup proxy
• Ensuring the patient has digital and paper copies and access to ACP documents
• Educating the patient on the best ways to share their decisions with others

ACP training is powerful. One study found that providers were more than twice as likely to conduct ACP discussions with their patients following clinician and staff education. Also, patients were 1.4 times more likely to have an ACP document in their electronic medical record.

Use educational resources to support patients 

Patients must understand Advance Care Planning’s purpose and process.

ThoroughCare offers integrated, evidence-based educational resources that patients can understand. Through multimedia education, care team members can facilitate conversations using videos to illustrate key points. 

These video aids take the pressure off of the clinician and provide trustworthy information, keeping focus on the patient’s situation and desires.

ThoroughCare equips providers and families to make informed, patient-compliant medical decisions

Access to the right technology, built around evidence-based standards and best practices, helps care teams overcome barriers to offering Advance Care Planning. 

By using ThoroughCare, provider organizations can confidently offer Advance Care Planning as a reimbursable Medicare service, mainly when provided in conjunction with the Annual Wellness Visit.